Choosing Between Mechanical and Tissue Heart Valves: A Patient's Guide

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• Mechanical vs. Tissue Heart Valves
• Mechanical Valve Benefits and Durability
• The Downside of Coumadin Anticoagulation
• Tissue Valve Lifespan and Factors
• Changing Guidelines and Patient Preference
• The Influence of TAVR on Valve Choice
• Making an Informed Decision

Mechanical vs. Tissue Heart Valves

Heart valve replacement surgery presents patients with two primary options. Dr. Tsuyoshi Kaneko, MD, clarifies that the main choice is between a mechanical heart valve and a tissue heart valve. A mechanical valve is an artificial prosthesis constructed from durable carbon materials. In contrast, a tissue valve, also known as a bioprosthetic valve, is crafted from biological materials. These are typically a pig's aortic valve or pericardial tissue from a cow.

Mechanical Valve Benefits and Durability

The foremost advantage of a mechanical heart valve is its exceptional longevity. Dr. Tsuyoshi Kaneko, MD, emphasizes that these valves are designed to last a lifetime. The need to explant, or remove, a mechanical valve is very rare. Such situations only occur in cases of valve thrombosis, where a blood clot renders the valve immobile, or if the prosthesis becomes infected. The rates of these serious complications are exceptionally low, making the mechanical valve a highly reliable long-term solution for aortic or mitral valve replacement.

The Downside of Coumadin Anticoagulation

The significant trade-off for a mechanical valve's durability is the mandatory requirement for lifelong anticoagulation therapy. Dr. Tsuyoshi Kaneko, MD, notes that patients must commit to taking the blood-thinning medication warfarin, commonly known as Coumadin. This is not an innocuous medication; its primary risk is bleeding. This burden of daily medication and the associated need for frequent blood monitoring to check coagulation levels is a major factor in a patient's decision-making process. The potential for serious bleeding events is a constant consideration.

Tissue Valve Lifespan and Factors

Tissue heart valves eliminate the need for long-term anticoagulation, which is their greatest benefit. However, Dr. Tsuyoshi Kaneko, MD, explains that the downside is that these biological valves wear out over time. The lifespan of a tissue valve is not fixed and varies significantly from patient to patient. A key factor is the patient's age and activity level at the time of implantation. A younger, more active patient's valve will open and close more frequently, leading to faster structural deterioration; a cow or pig valve may not even last ten years. Conversely, a tissue valve implanted in a sedentary 75-year-old may function well for 15 years or more.

Changing Guidelines and Patient Preference

Historical surgical guidelines were largely age-based. Dr. Tsuyoshi Kaneko, MD, states that patients aged 65 or younger were typically recommended mechanical valves, while those over 65 received tissue valves. This trend is now changing dramatically. The strongest recommendation in current guidelines from leading cardiology associations is ultimately the patient's preference. After being thoroughly informed of the risks and benefits of each valve type, the patient gets to choose the prosthesis that best aligns with their lifestyle and values.

The Influence of TAVR on Valve Choice

A major reason for this shift is the emergence of transcatheter aortic valve replacement (TAVR or TAVI). Dr. Tsuyoshi Kaneko, MD, highlights that this technology lowers the hurdle for choosing a tissue valve. If a surgically implanted tissue valve later fails, a new valve can often be placed inside the old one via a TAVR procedure. This "valve-in-valve" technique frequently eliminates the need for a second open-heart surgery, making the finite lifespan of a tissue valve a less daunting prospect for younger, active patients who wish to avoid Coumadin.

Making an Informed Decision

The choice between a mechanical and tissue heart valve is a profoundly personal one. As Dr. Tsuyoshi Kaneko, MD, concludes, the physician's role is to provide all crucial information about durability, anticoagulation, and future options. The patient, in consultation with their medical team and family, then makes the final decision based on a complete understanding of how each type of aortic or mitral valve replacement will impact their long-term health and quality of life.

Full Transcript

Dr. Anton Titov, MD: Heart valve treatment options are multiplying. There is biological tissue prosthesis for mitral and aortic valves. There are stented and stentless replacement heart valves. There is open-heart surgery and transcatheter valve replacement.

How to choose the correct type of heart surgery? How to choose the correct type of replacement heart valve for different patients?

What are benefits and risks of each type of heart valve surgery? How to choose the correct replacement heart valve?

Dr. Tsuyoshi Kaneko, MD: There are many options now available to patients. That is a very good question. That is a very difficult question too.

To start off, there are two types of replacement heart valves. I think that'll be the main answer to this question. One type of heart valve is called a mechanical heart valve. This artificial valve is made out of carbon.

Another heart valve for replacement is called a tissue valve. Tissue heart valve is made out of either pig valve or a cow pericardial tissue.

The benefit of mechanical valves is this. Mechanical heart valves last for a long time after you implant them. There are some situations where you have to exchange the mechanical heart valves, but those situations are very rare.

Either the mitral valve thrombosis happens, aortic heart valves get stuck and have to be taken out, or the replaced aortic valve gets infected. Those are the two cases when mechanical valve will need to be explanted. But the rates of mechanical heart valve problems are very low.

The downside of mechanical valves is that you have to be on a blood thinner. Typically this medication is called Coumadin. You are committed to a lifetime of using Coumadin. That is the biggest burden of receiving a mechanical heart valve.

Of course, the risk of Coumadin is bleeding. We will discuss it later, but it's important to note that Coumadin is not an innocuous medication. No, it's not.

On the other hand, the tissue mitral and aortic heart valves eliminate the need for Coumadin. These are cow heart valves or pig heart valves.

The downside of tissue valve is that it does wear out with time. It really varies on the time period of how long a tissue replacement heart valve takes to wear out.

You implant a tissue heart valve at a younger age. Then the aortic or mitral valve opens and closes much more because you are young and you are more active. Cow or pig heart valve may not even last ten years.

You may be 75 and you live a very sedentary life. Your pig aortic valve won't open that much. Therefore, cow mitral heart valve may last up to 15 years. It really varies how long tissue valve lasts.

That typically has been one of the deciding factors in the past. For age 65 or younger, patients used to be recommended mechanical heart valves. Anybody above 65 used to get tissue heart valves, but that trend is changing now for multiple reasons.

Dr. Anton Titov, MD: One is the emergence of TAVR/TAVI. Sometimes you receive a tissue heart valve and heart valve deteriorates. You can get TAVR later on. This eliminates open heart surgery. It lowers the hurdle of receiving tissue valves.

Second, patients are pursuing active lifestyles. They don't want anticoagulation. It means that a 55-year-old person who wants to cycle, who wants to go out and hike really aggressively.

Dr. Tsuyoshi Kaneko, MD: Those patients do not want Coumadin. Those patients are starting to choose tissue heart valves more often.

American Heart Association and American College of Cardiology provides guidelines of what valve to choose. But now the strongest recommendation is patient's preference.

Patients get to choose aortic or mitral valve for replacement based on all the information that they get.

Dr. Anton Titov, MD: The physician has to provide the important information for the patient. The patients ultimately get to choose if they want tissue or mechanical heart valve for replacement surgery.